Should you wear a sling for a rotator cuff injury. When is a sling necessary after rotator cuff repair. How long should you wear a sling after rotator cuff surgery. Can wearing a sling for too long cause problems. What are the alternatives to wearing a sling for rotator cuff injuries.

Understanding Rotator Cuff Injuries and the Role of Slings

Rotator cuff injuries are common shoulder problems that can cause pain, weakness, and reduced mobility. Many people wonder about the use of slings for these injuries, particularly after surgery. Let’s explore the key aspects of rotator cuff injuries and the use of slings in their treatment.

What is a rotator cuff injury?

A rotator cuff injury affects the group of muscles and tendons that stabilize the shoulder joint. These injuries can range from mild strains to complete tears. They are typically categorized into three grades:

• Grade 1: Minor strain with no significant tearing
• Grade 2: Partial thickness tear
• Grade 3: Full-thickness tear

Interestingly, having a grade 3 tear doesn’t necessarily mean surgery is required. Some individuals live with full-thickness tears without experiencing symptoms or even knowing they have them.

The Debate: To Sling or Not to Sling

The use of slings for rotator cuff injuries, especially after surgery, has been a topic of debate among medical professionals. Let’s examine both sides of the argument.

Arguments for using a sling

Proponents of sling use after rotator cuff repair surgery argue that it provides several benefits:

• Protects the surgical site during initial healing
• Reduces stress on the repaired tissues
• Improves patient comfort during recovery
• May decrease the risk of re-tear

Arguments against sling use

Those who advocate for limited or no sling use cite the following reasons:

• Potential for shoulder stiffness due to prolonged immobilization
• Risk of muscle atrophy
• Possible development of a frozen shoulder
• Delayed return to normal activities

When Should You Wear a Sling for a Rotator Cuff Injury?

The decision to wear a sling largely depends on whether you’ve had surgery and the severity of your injury. Here are some guidelines:

Post-surgical sling use

After rotator cuff repair surgery, most surgeons recommend wearing a sling for approximately six weeks. This includes wearing it while sleeping. The primary reason for this extended use is to protect the repair site and potentially reduce the risk of re-tear.

Non-surgical sling use

For non-surgical rotator cuff injuries, sling use is generally not recommended unless you’re experiencing severe, intractable pain that only improves when the arm is supported. However, prolonged use of a sling without surgical intervention may lead to increased pain, avoidance behaviors, and decreased muscle mass, potentially complicating the rehabilitation process.

The Importance of Proper Sling Use and Duration

If you’ve been advised to wear a sling, it’s crucial to understand how to use it correctly and for how long. Improper use or wearing a sling for too long can lead to complications.

How to wear a sling correctly

To ensure proper support and comfort, follow these steps:

1. Position the sling so that your elbow is at a 90-degree angle
2. Adjust the straps to distribute weight evenly across your shoulder and back
3. Ensure your wrist is supported in a neutral position
4. Check that your hand is slightly higher than your elbow to reduce swelling

Duration of sling use

The recommended duration for wearing a sling varies depending on the specific injury and treatment plan. For post-surgical patients, the typical duration is six weeks. However, your surgeon may adjust this based on your individual case. For non-surgical cases, if a sling is used, it’s generally recommended for short periods and should be discontinued as soon as possible to prevent complications.

Potential Risks of Prolonged Sling Use

While slings can be beneficial in certain situations, wearing them for extended periods can lead to various issues:

• Shoulder stiffness and reduced range of motion
• Muscle atrophy in the shoulder and arm
• Increased risk of developing a frozen shoulder
• Postural imbalances
• Potential for skin irritation or pressure sores

To mitigate these risks, it’s essential to follow your healthcare provider’s instructions regarding sling use and to engage in approved exercises and movements as part of your rehabilitation plan.

Alternatives to Sling Use for Rotator Cuff Injuries

For those looking to minimize sling use or seeking alternatives, there are several options to consider:

Conservative treatments

• Rest and activity modification
• Ice and heat therapy
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy exercises
• Gentle range of motion exercises

Advanced non-surgical options

• Corticosteroid injections
• Platelet-rich plasma (PRP) therapy
• Stem cell treatments
• Acupuncture

These alternatives aim to promote healing, reduce pain, and improve function without the potential drawbacks of prolonged sling use.

The Role of Physical Therapy in Rotator Cuff Recovery

Physical therapy plays a crucial role in the recovery process for rotator cuff injuries, whether treated surgically or conservatively. A well-designed physical therapy program can help:

• Restore range of motion
• Strengthen the rotator cuff and surrounding muscles
• Improve shoulder stability
• Prevent complications such as frozen shoulder
• Enhance overall shoulder function

Your physical therapist will work with you to develop a personalized treatment plan that may include manual therapy, targeted exercises, and modalities such as ultrasound or electrical stimulation.

Making an Informed Decision: Sling or No Sling?

Deciding whether to use a sling for a rotator cuff injury should be based on several factors:

• The severity and type of rotator cuff injury
• Whether you’ve undergone surgical repair
• Your individual pain levels and comfort
• The recommendations of your healthcare provider
• Your lifestyle and daily activities

It’s important to have an open dialogue with your healthcare provider about the pros and cons of sling use in your specific case. They can provide personalized advice based on your unique situation and help you make an informed decision.

Questions to ask your healthcare provider

To better understand your treatment options, consider asking the following questions:

• Is a sling necessary for my specific injury?
• How long should I wear the sling if it’s recommended?
• What are the potential risks and benefits of using a sling in my case?
• Are there any alternatives to sling use that might be appropriate for me?
• What exercises or movements can I safely perform while wearing a sling?
• How can I prevent complications associated with sling use?

By gathering this information, you can work with your healthcare team to develop the most effective treatment plan for your rotator cuff injury.

Long-term Outlook and Prevention of Future Injuries

While recovering from a rotator cuff injury, it’s important to consider the long-term outlook and take steps to prevent future problems. Here are some strategies to maintain shoulder health:

Ongoing shoulder care

• Maintain a regular exercise routine focusing on shoulder strength and flexibility
• Practice good posture to reduce stress on the shoulder joint
• Use proper form when performing activities that involve overhead motions
• Avoid repetitive shoulder movements when possible
• Listen to your body and avoid pushing through pain

Prevention strategies

To reduce the risk of future rotator cuff injuries, consider the following preventive measures:

• Gradually increase the intensity of shoulder exercises or activities
• Incorporate exercises that target all parts of the rotator cuff
• Maintain a balanced strength training program for the upper body
• Use ergonomic equipment and proper techniques in work and sports activities
• Take regular breaks during activities that involve repetitive shoulder movements

By implementing these strategies, you can help maintain the health of your rotator cuff and reduce the likelihood of future injuries.

Conclusion: Finding the Right Balance

The decision to use a sling for a rotator cuff injury is not always straightforward. While slings can provide important protection and support following surgery, their use must be balanced against the potential risks of prolonged immobilization. For non-surgical cases, alternative treatments and conservative measures often prove more beneficial than extended sling use.

Ultimately, the key to successful recovery lies in working closely with your healthcare team to develop a personalized treatment plan. This plan should take into account your specific injury, lifestyle factors, and long-term goals. By following professional guidance, engaging in appropriate rehabilitation exercises, and maintaining good shoulder health practices, you can optimize your recovery and reduce the risk of future rotator cuff problems.

Remember, every individual’s situation is unique, and what works best for one person may not be ideal for another. Stay informed, ask questions, and actively participate in your treatment decisions to ensure the best possible outcome for your rotator cuff injury.

Should You Wear a Sling For A Rotator Cuff Injury?

A sling does not need to be worn for a rotatory cuff injury. However, if you have undergone rotator cuff surgery, you will likely wear a sling for six weeks to allow the surgical site to heal and strengthen before introducing any traction forces.  

Can It Take Years To Heal From Back…

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Can It Take Years To Heal From Back Pain? #chronicpain #painrelief #strengthtraining

When should you wear a sling for a rotator cuff injury?

If you have recently had rotator cuff surgery, the majority of surgeons will recommend that you should wear the sling for six weeks, including when you’re sleeping. 

Some people have the concern that the shoulder will get too stiff if you immobilize it in a sling while at rest for six weeks, however, this fear is largely unfounded as the shoulder will be stiff, regardless. 

The primary reason that most surgeons want to wait six weeks before getting out of the sling is that it’s shown to have better outcomes, namely a decreased re-tear rate.  

It is worth noting that RTC retears are pretty common so I encourage you to read this article about whether you should even get the surgery or not.

Other reasons you should wear the sling if you haven’t had the surgery would be severe and intractable pain that only feels better when it’s in the sling. 

I’m generally not a huge fan of immobilizing a body part for an extended period of time if there has not been a surgical procedure, done, as it often creates more pain, avoidance, and worst of all, decreased muscle mass. This makes the rehab process more difficult. 

When should you not wear a sling for a rotator cuff injury?

As I shared briefly, above, I do not recommend you wear a sling any other time other than if you are post-op in weeks zero to six. 

If you are wearing a sling outside of that because it helps with pain, I would recommend considering not doing that, but also keeping it at a minimum if you must. 

It would be better to use ice, heat, and different exercises to see if you can improve symptoms.  

This will help keep your shoulder more mobile and reduce the risk of the shoulder locking up and turning into a frozen shoulder. 

Will the tear get worse if you don’t wear a sling?

There is no evidence that I have seen that says you are at a higher risk if you don’t wear a sling and you have a partial rotator cuff tear. 

That’s not to say that it’s not possible, however, if this issue was happening to me, I wouldn’t be worried about it. 

What is a rotator cuff injury?

A rotator cuff injury, often mistakenly called a rotary cup, is defined as pain, weakness, and decreased sensation of stability or any combination of those, at the shoulder. 

A rotator cuff can be strained or completely torn and these tears are graded in three stages. 

Grade one is a minor strain with no significant tearing. 

Grade two would be considered a partial thickness tear.

Grade three is defined as a full-thickness rotator cuff tear. 

Interestingly enough, having a grade three tear does not mean you will need surgery. In many cases, people live with full-thickness RTC tears and don’t even know they have them. This has been confirmed in several studies where they took MRIs of asymptomatic people who were then found to have rotator cuff tears. (source)

When do you need surgery?

I’ve explained this at length in another article, however, I’ll be brief, here. 

You likely need surgery if you can’t lift your arm, or have severe pain that has persisted longer than 6 months even after going through extensive, high-quality physical therapy. 

I’ve had too many clients come in over the years who can lift their arms straight over their head without any weakness whatsoever and who are told they need surgery. 

That is utter nonsense and whoever is recommending surgery to them needs their license to be revoked, or, at the very least, that person needs to be updated on the best available evidence around rotator cuff tears and when surgery is indicated, which I’ve also covered in other blog posts.  

What is a sling and how does it work?

Well, I think a sling is pretty self-explanatory once you see a picture…

Its main function is to immobilize the shoulder and reduce the traction forces that are experienced at the shoulder joint. 

Since the rotator cuff muscles are active “at rest” to stabilize your shoulder, without a sling, they are always working when you are in an upright position. 

There are two basic types of slings that are used for a RTC repair.

Shoulder sling with an abduction pillow (amazon link to Don Joy – this is the most popular sling), and then just some run-of-the-mill, old-school slings without the abduction pillow. 

Abduction just means that the arm is away from the body. It is the action of moving the arm away from the body and increasing the angle as measured by looking at the armpit. 

The abduction pillow places the shoulder in about 30 degrees of abduction which further reduces the traction forces that are placed upon the shoulder if you were in a regular sling without the abduction pillow.  

My clients have said these are much more comfortable than the regular slings. 

The only downside about the Don Joy slings and other slings with abduction pillows is that they are a bit bulkier and so you might have to be a bit more creative when walking through doorways and such. But, this only lasts for six weeks or so. 

Conclusion

Slings are widely used post-op for rotator cuff repair however they do not need to be used if you are not undergoing a surgical procedure. 

It’s best to find a rehab program that works for you, first, try that out, and then if that doesn’t work then proceed with a surgical procedure. This is always on a case-by-case basis. 

If you have any more questions and would like to speak to me directly please submit a consultation request by clicking the button below. 

Thank you!

Dr. Nate Kadlecek, PT

Nate Kadlecek, PT, DPT is a Columbia University-trained physical therapist committed to providing high-quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low-quality treatment methods, and the over-diagnosis of pain conditions.
He competes in powerlifting and has recently taken up longer distance running, played football and baseball in college, successfully completed one mountaineering trip (barely), Shoe Dog by Phil Knight (a memoir about Nike) is his all-time favorite book and captures his own ethos, and few things get him as excited as presenting to groups of people eager to learn about the science of pain and talking about future tech and its integration with health.

Postoperative Care

1. Home
2. Patient Care
3. Services
4. Shoulder & Elbow
5. Overview
6. Rotator Cuff
7. Postoperative Care

Sling Instructions

After surgery, your shoulder will be placed in a sling as directed by your doctor. The sling is used to limit motion of your shoulder so that the rotator cuff tendon can incorporate and heal. In some cases where the repair must be carefully protected, your arm may be placed in a sling with a pillow that is attached around your waist. It is very important to wear your sling as directed by your doctor after surgery. 

• The sling is typically used for 4 to 6 weeks after surgery. 
• You should not do any reaching, lifting, pushing, or pulling with your shoulder during the first six weeks after surgery.
• You should not reach behind your back with the operative arm.
• You may remove your arm from the sling to bend and straighten your elbow and to move your fingers several times a day.
• You may remove the sling to bathe, dress, and perform elbow range of motion several times a day.

Watch the video below to see how you should properly wear your sling.

Your Diet

We recommend that you eat a light diet the evening of surgery and the next day. You may resume eating a regular diet as soon as you tolerate it.

Pain Management

When you are discharged from the hospital, you will be given a prescription for pain medicine. You may take this medicine as prescribed.

Ice Therapy

You will be given the option to purchase a cold pack machine. This machine has a sleeve which is attached to an ice cooler. You place ice and some water in the cooler and plug this in to a regular outlet. This circulates cold water through the shoulder sleeve providing relief of pain and swelling after surgery. If you do not purchase a cold pack, you may use ice bags or frozen vegetable bags to ice your shoulder.

• You should keep ice on the shoulder for the first 48-72 hours after surgery.
• Ice your shoulder two to three times per day for the first week, especially before sleep.
• We do recommend that you put a t-shirt or a thin towel between you and the sleeve so that it doesn’t injure your skin.

Caring for Your Surgical Incision

• You may remove your dressing and shower 48 hours after surgery if you do not have a pain catheter. If you had a biceps tenodesis surgery, you should leave your dressing on for five days after surgery. 
• If you have a pain catheter, this should be removed by a family member 72 hours after surgery along with the shoulder dressing before showering.
• You should not get in a tub or pool and immerse the incisions underwater for six weeks, but you may get in the shower and let the water run over them. Pat the incisions dry afterwards, and place Band Aid’s over the incisions. There is no need to place any ointment over the incisions.
• If you notice drainage, swelling or increased pain five days after surgery please call the office.
• Redness around the incision is very common and should not be a concern. However, please call our office if you have:
  • Redness and drainage five days after surgery
  • Redness spreading away from the incision
  • Redness and a fever

Sleeping

It is often very difficult to sleep in the week or two following rotator cuff surgery. The surgery itself may interfere with your sleep-wake cycle. In addition, many patients have increased shoulder pain lying flat on their back. We recommend that you try sleeping in a recliner or in a reclined position in bed. You may place a pillow between your body and your arm and also behind your elbow in order to move your arm away from your body slightly. You should wear your sling when you sleep.

Driving

Operating a motor vehicle may be difficult due to your inability to use your operative arm. If you should have an accident or get pulled over while wearing a sling, authorities may consider that driving while impaired. The decision to drive is based on your comfort level with driving essentially one-handed. If you need to drive, and a rotator cuff repair has been performed, you should wait at least until you have
seen your surgeon at the first postoperative visit. No one should operate a motor vehicle while taking narcotic medications.

Healing and Recovery
Tendon tissue heals much more slowly than other tissues in your body. For example, if you cut your skin, it will typically heal in seven to 10 days. Rotator cuff tendon tissue, however, heals over a three month period. After three months, it typically takes another two to three months to regain good
shoulder strength, depending on the size of the rotator cuff tear. While the goal of surgery is to restore a pain-free and functional shoulder, there may be some limitation based on the age and the size of the tear. In larger tears or tears in older patients, the tendon repair may not heal. In these cases, pain relief and function are usually good; however, some weakness usually remains in the shoulder. In general, about 90% of patients are satisfied with their shoulders after rotator cuff repair, and have significant improvements in pain and function after surgery.

Physical Therapy
The decision to prescribe physical therapy and when to start these activities is made on a case-by-case basis. This will be discussed with you on your first postoperative visit.  You may be instructed by your surgeon or recovery room nurse to begin gentle range of motion exercises on the day of surgery. These will be self-directed exercises that you start on your own.

Surgical Risks and Complications

The list below includes some of the common possible side effects from this surgery. Fortunately complications are very rare. Please note that this list includes some, but not all, of the possible side effects or complications.

Complications may include: complications from anesthesia, infection (very rare with arthroscopic procedures), nerve injury (extremely rare), blood vessel injury (extremely rare), bleeding (extremely rare), shoulder stiffness, failure of repair (failure of the tendon to completely heal to bone), failure of the anchors or sutures, failure to improve your symptoms as much as you had hoped, a blood clot can form in your arms or legs and very rarely travel to your lungs, complex regional pain syndrome (a painful condition involving the arm).

>>Next topic: Medications to avoid before and after surgery

Treatment Rotator cuff injury

WHAT IS A ROTATIONAL (ROTATORIC) SHOULDER CUFF AND WHAT IS IT FOR?

Rotational (rotator) cuff of the shoulder – includes the supraspinatus, infraspinatus, small round and subscapularis muscles. These muscles are necessary to stabilize the head of the humerus and prevent it from moving when moving in the joint. In addition, these muscles allow for rotational movements in the shoulder in all directions.

The subscapularis muscle rotates the arm inward, the supraspinatus muscle raises the shoulder and “anchors” it, i.e. presses the head of the humerus into the articular cavity of the scapula when the shoulder is abducted to the side. In this case, the main abduction force is determined by the deltoid muscle, and the supraspinatus muscle works as a commander, directing the efforts of the deltoid muscle. The infraspinatus muscle rotates the shoulder outward, and the small round muscle rotates outward and brings the arm to the body. Damage to at least one of the four muscles leads to a sharp limitation of movement and loss of function of the shoulder joint.

CAUSES OF DAMAGE OR RUPTURE OF THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Rotator cuff injury can result from acute trauma. In this case, patients often describe a specific injury, after which pain appeared and the function of the shoulder was impaired.

In some cases, rupture of the rotator cuff is the result of chronic microtrauma to the muscles. Most often this occurs in persons whose professional activities are associated with frequent elevated position of the hand or throwing movements. For example, athletes in sports such as baseball, tennis, weightlifting and rowing. Constant microtraumatization of the tendons of the rotator cuff when hitting the ball, serving, throwing can lead to micro-ruptures of muscle fibers, the muscles gradually become thinner and over time, even with a minor injury, they can easily tear.

The rotator cuff tendons are prone to overstressing in teachers who write with chalk on a blackboard with their hand up, painters who paint walls, builders, and the like.

In some patients, rupture of the rotator cuff may be due to the development of degenerative-dystrophic changes in the muscles associated with aging, for example, in the elderly or a genetic predisposition.

TYPES OF DAMAGE OR RUPTURES OF THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Due to the cause of the rupture – traumatic or degenerative ruptures. According to the nature of the damage, partial and complete ruptures are distinguished. Partial ruptures do not pass through the entire thickness of the tendon, full ones extend through the entire thickness of the layers of the cuff. Traumatic injuries are divided into fresh, stale and chronic.

SYMPTOMS OF DAMAGE TO THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Signs of damage to the rotator cuff are pain and weakness in arm abduction or external rotation of the shoulder.

Pain intensifies in certain phases of movement, especially when abducting the arm

at an angle of 70 – 120 °.

DIAGNOSTICS OF DAMAGE TO THE ROTATOR CUFF:

Diagnostic tests:

To diagnose damage to the rotator cuff, special tests are used in which the doctor, bringing the patient’s hands to a certain position, evaluates the motor ability of the injured arm, and observes the patient’s reaction to his actions. The most informative tests are for weakness of abduction and weakness of external rotation of the shoulder. With extensive damage to the rotator cuff, symptoms of a falling arm are also characteristic (the patient cannot hold the passively abducted arm) and raising the shoulder girdle when trying to abduct the arm (Leclerc’s symptom).

Ultrasound – diagnostics

MRI – research

X-ray – research

TREATMENT OF A ROTATOR CUFF INJURY:

Treatment of a rotator cuff injury can be conservative or surgical. Conservative treatment is indicated for partial injuries, when there is hope for restoration of function without surgery. Conservative treatment is carried out along with immobilization of the shoulder joint with a special bandage (orthosis), and includes:

physiotherapy, the use of anti-inflammatory and analgesic drugs, with severe pain – blockade with long-acting glucocorticoids. A very good clinical effect is given by intra-articular injections of platelet-rich plasma into the shoulder joint (“growth factors”, PRP).

If the duration of unsuccessful conservative treatment exceeds 2-3 months, it is necessary to raise the question of surgery.

SURGICAL TREATMENT OF DAMAGES TO THE ROTATOR (ROTATOR) CUFF OF THE SHOULDER:

Repairing a torn rotator cuff tendon is a fairly complex operation. Reconstruction of the rotator cuff can be performed both openly, through an incision on the shoulder, and arthroscopically. The disadvantages of open surgery are the need for large, traumatic incisions on the shoulder to provide access to damaged tendons, which carries a high risk of side effects, and a long recovery after surgery.

In our Medical Center, surgical treatment of rotator cuff injury is performed in a modern way, without incision of the joint – under arthroscopic control. Instead of an incision, local mini-punctures are performed, into one of which an arthroscope with a video camera is inserted, and into the other, instruments for the operation. An enlarged image from the video camera is transmitted to the video monitor, which allows the doctor to examine in detail all the structures of the joint and identify the location of the damage.

The essence of the arthroscopic operation is that the rupture is sutured, and if the tendon is torn off from the place of fixation, then a suture is performed using special “anchor” fixators.

At the first stage of the operation, the joint is cleaned – the removal of all non-viable, degenerative – altered tissues of the rotator cuff. Then the area of ​​the humerus where the rotator cuff was torn or torn off is cleared of soft tissue remnants so that the tendon grows better to it. Usually, 2-3 anchors are required to fix a torn tendon. The latch consists of an anchor and threads. The anchor is attached to the bone, and the tendon is stitched with threads.

The choice of a specific type of anchor is made by the operating surgeon, but in general, the patient should also be informed about which anchor is planned to be used in his case. We recommend using clamps from world-famous companies that have proven themselves for a long time.

REHABILITATION AFTER SHOULDER ARTHROSCOPY:

Properly performed surgery allows you to quickly start active rehabilitation, to prevent the development of complications and optimize the recovery time.

After shoulder arthroscopy, the arm is immobilized in the abduction position for several weeks using a special splint. Such immobilization reduces tendon tension and reduces the risk of re-rupture, creates favorable conditions for better healing of the tendon. The duration of immobilization is determined by the surgeon who performed the operation, since only he can assess the condition of the tendons and the strength of the suture.

Already from the first weeks after shoulder arthroscopy, patients are recommended to perform special exercises aimed at developing movements in the shoulder joint. However, their intensity and sequence should be selected by the operating doctor and an experienced rehabilitation specialist.

In our Medical Center, patients after shoulder arthroscopy are offered a whole range of rehabilitation measures. The rehabilitation program is selected individually and includes:

Special exercises and exercise therapy by rehabilitators of our Medical Center using the kinesiotherapy method. Exercises are aimed at improving the range of motion in the joint, preventing the development of contractures, increasing strength and endurance in the muscles of the shoulder girdle. Exercises are selected on an individual basis and performed on professional equipment in the rehabilitation room, under the supervision of experienced instructors – rehabilitologists. Some of the exercises are signed for the patient to carry out at home.

Physiotherapy on professional equipment from BTL: magnetotherapy, ultrasound therapy with the introduction of drugs, electrotherapy – reduce pain and swelling in the operated shoulder, prevent the formation of adhesions and scars, promote better healing, restore muscle tone.

TRUST THE CARE OF YOUR HEALTH TO REAL PROFESSIONALS!

Arthroscopic treatment of a rotator cuff tear

Rotator cuff injury.

The shoulder joint is the most mobile joint in the human body. It allows us to raise our hand, put it behind our back, reach our own back of the head. It is believed that it was thanks to labor and one’s own hands that a person became a person, but it would not be an exaggeration to say that the whole variety of functions of the human hand is based precisely on the amazing mobility of the shoulder joint. Movements in the shoulder joint are carried out in all three planes, but for an increase in the range of motion in the joint, we have to pay with a decrease in its stability and a high risk of damage to its structures, which include the rotator cuff of the shoulder.

Anatomical structure of a normal shoulder joint.

The shoulder joint is formed by three bones: the head of the humerus, the glenoid cavity of the scapula and the clavicle, which is not anatomically connected with the joint, but significantly affects its function.

The head of the humerus corresponds in shape to the articular cavity of the scapula, also called the glenoid cavity (from the Latin term cavitas glenoidalis – articular cavity). Along the edge of the glenoid cavity of the scapula there is an articular lip – a cartilaginous roller that holds the head of the humerus in the joint.

The tough connective tissue that forms the capsule of the shoulder joint is essentially the ligament system of the shoulder joint that helps the head of the humerus stay in the correct position relative to the glenoid cavity of the scapula. The ligaments are firmly fused with the thin capsule of the joint. These include the coraco-brachial and articular-humeral ligaments (has three beams: upper, middle and lower). Also, the shoulder joint is surrounded by powerful muscles and tendons, which actively provide its stability through their own efforts. These include the supraspinatus, infraspinatus, teres minor, and subscapularis, which form the rotator cuff. Each of these muscles performs its own function: the subscapularis rotates the arm inward, the supraspinatus – raises the shoulder and “anchors” it, i.e. presses the head of the humerus into the articular cavity of the scapula when the shoulder is abducted to the side. In this case, the main abduction force is determined by the deltoid muscle, and the supraspinatus muscle works as a commander, directing the efforts of the deltoid muscle. The infraspinatus muscle rotates the shoulder outward, and the small round muscle also rotates outward and brings the arm to the body.

Together they function as a rotator cuff.

Rotator cuff

The supraspinatus muscle is located above all in the rotator cuff, while its tendon passes in a narrow space between the acromial process of the scapula and the head of the humerus, which determines the propensity for injury to the tendon.

Rotator (rotator) cuff of the shoulder: general appearance, tenopathy and infringement of the tendons of the rotator cuff in the subacromial space (impingement – syndrome)

You can learn more about the anatomy of the rotator cuff and the anatomy of the shoulder joint on our website (click on the mouse to go to the articles about the anatomy).

Causes of diseases and injuries of the rotator cuff

The tendons of the muscles of the rotator cuff, like all other tendons, have a relatively poor blood supply. Insufficient blood supply to the tendons of the rotator cuff leads to the frequent development of degenerative changes: the so-called tenopathy occurs. It should be noted that not only insufficient blood supply contributes to the development of tenopathy (a number of scientists generally deny the role of blood supply in the development of tenopathy). Another reason for the development of tenopathy is a hereditary pathology of the connective tissue. Tendons are mainly made up of a special protein called collagen, which comes in 4 types. With an abnormally high percentage of collagen types 3 and 4, tenopathy develops more often. In general, tenopathy can develop in any of the tendons of the rotator cuff (and in several tendons at the same time), which can lead to pain in the shoulder joint during movements in which the corresponding muscle is involved. For example, with tenopathy of the tendon of the supraspinatus muscle, the pain increases when the arm is abducted to the side, with tenopathy of the subscapularis muscle, when bringing a spoon or fork to the mouth, when combing, when putting the hand behind the back. These tenopathies are often referred to as humeroscapular periarthritis , but this is an absolutely illiterate diagnosis, which has already been abandoned around the world several decades ago. “Shoulohumeral periarthritis”, manifested by pain in the shoulder, can actually be not only a tenopathy of one or another tendon of the rotator cuff, but also a number of other diseases, which deserves consideration in a separate article. In addition, the development of tenopathy contributes to the use of certain antibiotics (fluoroquinolones).

The most common cause contributing to the development of tenopathy is chronic traumatization of the tendons, which is possible with two principal options:

Three types of anatomical shape of the acromial process (lateral view). The hook-like shape of the acromial process contributes to traumatization of the tendons of the rotator cuff

With age, degenerative changes in the tendon progress, tenopathy becomes more pronounced, the tendon weakens and may rupture. The most common tendon rupture occurs at the age of 35-55 years. However, with a sufficiently severe injury (fractures of the greater tubercle of the humerus, other fractures of the proximal part of the humerus, dislocations in the shoulder joint, etc.), a rupture can occur without previous tenopathy, i.e. in relatively young people.

Complete supraspinatus tendon rupture and partial subscapularis tendon rupture

Symptoms

shoulder due to injury occurs against the background of previous degenerative changes (tenopathy) . The gap is characterized by a sharp increase in pain and weakening of the arm, up to the complete inability to move the arm. Ruptures are partial or complete, when the tendon of a particular muscle is completely torn off from its attachment to the humerus. The intensity of pain depends on the size of the gap – as a rule, the larger the gap, the greater the pain, and the greater the restriction of movement. With partial ruptures, the possibility of hand movements is preserved.

The localization of pain depends on which rotator cuff tendon is injured. Most often, the supraspinatus tendon is damaged, which is usually manifested by a complete inability to move the arm to the side (with a complete rupture) or increased pain when the arm is abducted to the side in an amplitude of 30 to 60 degrees. Many patients note that they cannot sleep on the side of the affected shoulder joint.

Diagnosis

To make a diagnosis, the doctor will ask you about the mechanism of the injury, the age of the injury, the nature of pain in the shoulder, whether and how long the shoulder hurt before the injury. Let us recall once again that with significant tenopathy, tendon rupture can occur without injury at all.

Next, the doctor conducts an examination, during which he conducts special tests (moves your hand or asks the patient to make a special movement), during which it is already possible to find out with a high degree of probability which particular tendon is damaged.

As a rule, when the tendon is completely torn (or detached from its attachment to the bone), the movement for which this muscle is responsible is impossible.

With partial tears, the ability to move the arm is preserved, but the movements are painful.

An x-ray is mandatory, which, in case of ruptures of the rotator cuff tendons, can reveal characteristic signs on the lower surface of the acromial process – the so-called subchondral sclerosis. It is formed as a defensive reaction of the bone against repeated impact of the head of the humerus and the lower surface of the acromion (impingement syndrome), and these impacts lead to damage to the tendons of the rotator cuff, cause their tenopathy, and, ultimately, rupture. Of course, the absence of these signs on the radiograph does not mean that the rotator cuff tendons are not damaged, but the presence of these radiological signs with a high degree of probability indicates problems with the rotator cuff tendons. On the x-ray, it is important to evaluate the acromioclavicular joint: arthritis of this joint can cause similar pains.

X-ray: impact of the humeral head (blue arrows) and the inferior surface of the acromial process (red arrows) damages the supraspinatus tendon passing between them.

In case of an unclear diagnosis and in order to clarify the extent of damage, ultrasound or magnetic resonance imaging is performed, which allows using magnetic waves to see and capture soft tissues and bones in the form of layered sections.

Magnetic resonance imaging showing complete supraspinatus tendon rupture

Treatment

Initial treatment 90 140 for acute, recent rotator cuff tendon rupture is to reduce pain. As a rule, non-steroidal anti-inflammatory drugs are used, such as aspirin, voltaren, xefocam, etc. Also, in the acute period, it is necessary to observe rest for the sore hand – the hand is immobilized on a scarf bandage or on a special abduction splint. To reduce pain and swelling, applying ice packs wrapped in a towel to the shoulder is effective.

Gusseting Rules

A special abduction splint used to treat rotator cuff tendon ruptures. Most often, the tendons of the supraspinatus muscle are torn off from the place of its attachment to the humerus. Immobilization of the arm in the abduction position brings the end of the torn tendon closer to the place of its attachment to the humerus. The same abduction splint is also used after surgery for rotator cuff tendon ruptures

Complete rupture of the supraspinatus tendon and partial rupture of the subscapularis tendon. When the arm is abducted to the side, the torn ends of the tendon come together. The red arrow shows the axis of the humerus. On the left – the shoulder is brought to the body, on the right – the shoulder is laid to the side.

Conservative therapy. With tenopathy and minor, small tears, when the movements in the shoulder joint are preserved, conservative therapy is prescribed. After pain relief, light physical exercises are prescribed to develop the joint. In a later period, strength exercises are added to these exercises aimed at strengthening the muscles of the upper limb. This will gradually return the patient’s arm to its previous range of motion. Usually the duration of conservative therapy is from 6 to 8 weeks. During this time, pain in the shoulder completely stops, and there is a partial restoration of strength in the muscles of the arm.

Surgical treatment. With significant tears, conservative treatment is futile, because the broken ends simply cannot heal. However, the size of the gap and the very fact of the presence of a gap are not at all the criteria by which the need for surgery is assessed, since sometimes even with complete gaps, the movements in the shoulder joint are preserved or practically painless due to the fact that the function of the torn tendon is partially taken over by neighboring tendons. However, with complete ruptures, this does not occur often.

Operation is indicated if:

• there is a complete tear that makes movement in the shoulder joint impossible or restricts some movement;
• there is a partial tear that limits movement, causes pain;
• conservative treatment was unsuccessful.

During the operation, the torn tendon is pulled back to its place of attachment and sutured.

The essence of the operation is that the rupture is sutured, and if the tendon is detached from the place of fixation, then I perform the suture using special “anchor” fixators. At the first stage of the operation, all non-viable, degeneratively altered tissues of the rotator cuff are removed. The area of ​​the humerus where the rotator cuff has been torn or torn off is then cleared of soft tissue remnants in order for the tendon to grow. Breaks are different in their form. The most common are U-shaped and L-shaped gaps.

Quite often, 2-3 already mentioned anchors are required to fix a torn tendon. This retainer consists of an anchor and threads. The anchor is attached to the bone, and the tendon is stitched with threads. The choice of a specific type of anchor is made by the operating surgeon, but in general, the patient should also be informed about which anchor is planned to be used in his case. We recommend using clamps from world-famous companies that have proven themselves for a long time. First of all, we can distinguish FASTIN®, PANALOK , VERSALOK ™, BIOKNOTLESS ™, GII, HEALIX ™ from DePuy Mitek (a division of Johnson and Johnson), PushLock® Knotless Anchor from Arthrex and TWINFIX ™ from Smith & Nephew.

Repair of a torn rotator cuff tendon is a rather complicated operation. Reconstruction of the rotator cuff can be performed both openly through an incision and arthroscopically, i.e. without the traditional cut. Through one puncture 1-2 centimeters long, a video camera (arthroscope) is inserted into the joint and all injuries are examined from the inside. Through 1-2 other small punctures, special instruments are introduced into the joint, with which the tendon suture is performed.

Repair of a torn tendon is not possible in all cases. If a sufficiently long period of time has passed between the moment of injury and the operation, then cicatricial degeneration of the muscle and tendon may occur, as a result of which it will be impossible to tighten this tendon during the operation to fix it to the bone. In other cases, pronounced degenerative processes can be observed in the tendon, which leads to a significant decrease in the breaking load. In this case, even after successful reconstruction of the tendon, a relapse of the disease is likely in the near future.